PIE (Clinical) Notes: How to Write a PIE Note
This section provides an overview for how to create a PIE note in OnTarget Clinical.
If any notes have already been created in the system, a list of notes will populate after clicking on the Notes Desktop icon. This list will only display the notes for the user who is logged in, unless the user is a supervisor or a super user. If the user is a supervisor, all notes that are linked to that particular supervisor are displayed. If the user is a super user, all notes for the clients in the assigned cost center will be displayed. The filters on the left of the screen can be used to further limit the list view. Double-clicking on the line item will take the user to that particular note to either review or to edit.
To add a new note to the system, click "Add Note". Select the client.
The security settings for the user logged into the system will determine the clients displayed in the drop-down list. To verify which clients are visible in the drop down, go to the Options menu to see if the "Assigned Clients only" box is checked. If this box is checked and the client name required to write a note is not visible, the client will need to be added to the user's roster under the Employees Desktop.
If the system is being used to schedule services, then notes should be created from scheduled events. Doing so will ensure that the units flow correctly in the system and can be accurately counted. It is important to understand that the unit count will be inflated if scheduled events are not pulled into notes. To create the note from the schedule, move to the schedule drop-down field. Select the record that matches the service and date of the note to be created. Once the scheduled record is selected, confirm that all populated fields are correct, editing where necessary if applicable. Company settings determine whether or not any of the fields that pull in from the schedule can be changed.
If services are not being scheduled in the program, skip over the "schedule" field and select the "service date" by clicking on the calendar icon.
Next, select the authorized service that was provided. Each service is associated with the end date of an authorization. Selecting the correct service provided is critical so that the corresponding goals for that service are displayed.
After selecting the service, a "Service Unit Utilization" graph appears to the right of the screen. Hovering a mouse pointer over any color on the graph corresponds to the unit count. "In Process" reflects all units that are tied up in the system, but not yet billed. These units could consist of time entered on the schedule or time against an approved note that has not been billed.
The template field should auto-populate to PIE Note based on the service selection. If PIE Note is not auto-populated, open the drop-down and select this option. This template will pull in the proper note format for this style of note. Note templates are linked to services by going to List Configuration–>Services–>State Services, choosing the service, and setting the Default Template from the drop down box.
Enter in the "Start Time" and "End Time" or "Duration" (it is one or the other based upon the way a particular company intends to capture time per service). Be sure to include AM and PM (tip: click "A" for AM and "P" for PM).
The username logged into the system will auto-populate in the Caregiver field. There should be no reason to change this as the user logged into the system is the caregiver who is documenting the service note.
The supervisor name will also auto-populate. The supervisor name can be changed if necessary to reflect the actual supervisor responsible for reading and approving the note.
Once all of the required fields have been entered, the "Save" button can be clicked at any time. It is recommended to periodically save. While the system will provide a notification if the session is about to expire, if the system does not get a response to this message, the user will be logged out and any unsaved work will be lost.
Start documenting the service by either selecting the goal(s) or by keying in the goal(s) for the purpose of contact. It is recommended that goals be entered on the treatment plan so that the goals are synced to the note. The goals are entered in the Clients Desktop in the Treatment section. See "Adding Goals to a Treatment Plan" for details.
Next are sections to document the interventions provided and the effectiveness of those interventions.
These 3 sections, Purpose, Intervention and Effectiveness are standard to a PIE Note, meaning these are the system defaults. There are options for customizing note templates if need be. If for example, any of the sections require a different name, custom labels can be created. Another option may be to add additional fields if it is necessary to capture more information. The ability to customize the note is managed under the Configure Desktop.
The last step in the workflow for creating a PIE note is to sign the note. The user is required to key in their password when signing the note to authenticate their signature. This is the same password that is used to login to the program.
Validation warning messages may be presented if there is anything systematically out of compliance with the note. The system will check to make sure that the following are in place:
- The caregiver’s certifications are up to date and not incomplete or expired
- The client’s consents are up to date and not incomplete or expired
- There are enough units left on the service authorization
- The time on the note does not overlap with another note
- All required fields have been entered
Below is an example of a validation warning message:
When a validation warning message is presented, users have the choice of clicking "Yes, continue processing" or "No, cancel" (depending on the security settings for validation warnings). By clicking yes, users may proceed with signing the note. From there, the supervisor will review the note for approval. The supervisor will also receive the same warning messages and may determine at that time that the note cannot be approved for billing or for payroll. If "No, cancel" is chosen, the note will not be signed and therefore will not be eligible for the supervisor to approve. Supervisors/system administrators typically determine how users should handle these warning messages.
A work flow chart showing the status of a note is available to reference as the note moves through the life cycle in the program (upper right of the note information screen). This will help users understand if the note has been approved for billing, approved for payroll and whether or not it’s been billed. See example below. See the "Notes Workflow" section of the user guide for more detail.
There are several tabs within each note.
- Tasks: this tab is used for internal communication between the supervisor and the caregiver on the note. Typically this is used when the supervisor cannot approve the note and needs to provide the caregiver with the needed corrections. The caregiver can then respond to the task and alert the supervisor when the task has been completed.
- History: this tab provides an audit trail with a timestamp of all actions taken on every save.
- DMS: this tab stores the electronic record of the note. Every time a note is signed and/or unsigned a new electronic record is created. Notes can be viewed by clicking on the green arrow.